☐HARD COPY-CONTROLLED ☐ELECTRONIC-CONTROLLED

POLICY AND PROCEDURES

DAR AL AYOUN HOSPITAL FOR ONE DAY SURGERY L.L.C - Central Sterile Supply Department
Transporting Soiled Instruments
Document No.: Edition No.: 1 Standard Compliance: ☐ ☐

Date Developed: Effective Date: Next Revision Date

Prepared by: Reviewed by: Approved by:

1 PURPOSE

1.1.To provide cross contamination during transportation of soiled instruments within Dar Al Ayoun Hospital
1.2.To assure that the standard precaution is followed always.

2 SCOPE

2.1.Dar Al Ayoun Hospital staff involved to medical device/instrument usage, processing and sterilization.

3 ABBREVIATION AND DEFINITION

3.1.CSSD: Central Sterile Supply Department

3.2.PPE: Personal Protective Equipment

3.3.IFU: Instruction for use

3.4.Hermetic trolley – any rigid enclosed, puncture proof, leak proof and sealable container designated for
transport of medical instruments.
3.5.Dispatch Staff: staff including dental assistant and other clinic specialty nurses.

4 POLICY

4.1.CSSD Technician including support staff should maintain and observe always safe collection, handling
and transportation of soiled instruments from specialty clinic and/or to CSSD.
4.2.Soiled medical instruments should be handled in manner that reduces risk of exposure and/or injury to
personnel and patients or environmental contamination and IFU recommendations are observed.
4.3.Infection prevention and control measures should be fully observed and implemented during transport of
soiled instruments.

4.4.Access to designated hermetic trolley should be under control and maintenance of CSSD staff.

4.5.Education and training on handling and training on handling and transporting soiled instruments should
 be given to involved staff emphasizing infection prevention and control.

5 PROCEDURE

5.1.Specialty clinic (e.g. dental, OB etc) that requires CSSD service will notify CSSD staff post procedure to
collect used or soiled instruments. Pre-cleaning of soiled instruments will not be performed in the clinic.

5.2.Instruction per use (IFU)

5.3.CSSD Staff or support staff to collect soiled instruments using designated hermetic trolley one at a time.

5.4.Soiled instruments should be placed directly by dispatch staff inside hermetic trolley.

5.5.Receiving log sheet should be signed and countersigned by dispatch staff and CSSD Staff, respectively
after receipt of soiled instruments.

5.6.CSSD Staff and dispatch staff to observe infection prevention and control measures always using
appropriate PPE.

5.7.Access to designated hermetic trolley containing soiled instruments will be restricted, locked and under
control of CSSD staff only.

5.8.Hermetic trolley containing soiled instruments should be directly transported to pre-wash area without
delay.

5.9.Hermetic trolley should be disinfected after each use by the CSSD technician or support staff.

6 RESPONSIBILITIES

6.1.CSSD technician and support staff are responsible for the compliance of this policy.

6.2.Specialty clinic nurses and dental assistance should observe and comply to this policy.

7 REFERENCES

7.1.The basics of sterile processing 6th edition 2016(updated and revised)

7.2.Association for advancement of medical instrumentation. Water reprocessing of medical devices. AAMI
TIR34:2014 Arlington(VA):AAMI, 2014

7.3.Occupation safety and health administration. Occupational exposure to blood-borne pathogens. 29 CFR
1910.1030

7.4.Centers for disease control and prevention. Consideration for selective clothing used in healthcare for
protection against microorganisms in blood and body fluids. Accessed February 24, 2016

7.5.Joint Commission International Accreditation Standards for Ambulatory Care, 3rd Edition
8 ATTACHMENTS

8.1.N/A

9 REVISION HISTORY

REVISIO REVISION AFFECTED

DESCRIPTION INITIATED BY: APPROVED BY:
N LEVEL DATE PAGE/S

1 Newly Developed Policy and Procedures - -